CARDIOVASCULAR EFFECTS OF THE TOBACCO HEATING SYSTEM (THS) 2.2 COMPARED WITH CONTINUED SMOKING Athens, Greece Dr. Patrick Picavet, M.D., on behalf of: Baker, Gizelle; Haziza, Christelle; Hoeng, Julia; Ivanov, Nikolai; Luedicke, Frank; Maeder, Serge; Peitsch, Manuel; Phillips, Blaine; Poussin, Carine; Vanscheeuwijck, Patrick Philip Morris International 9 June 2018
The Scientists Our contact details Gizelle Baker Christelle Haziza Julia Hoeng Nikolai Ivanov Frank Luedicke Serge Maeder Manuel Peitsch Blaine Phillips Patrick Picavet Carine Poussin Patrick Vanscheeuwijck
Creating a New Category: Reduced-Risk Products Reduced-Risk Products ( RRPs ) is the term we use to refer to products that present, are likely to present, or have the potential to present less risk of harm to smokers who switch to these products versus continued smoking. Our contact details We have a range of RRPs in various stages of development, scientific assessment, and commercialization. Because our RRPs do not burn tobacco, they produce far lower quantities of harmful and potentially harmful compounds than found in cigarette smoke.
Our contact details Tobacco Harm Reduction
What Is the Objective of Harm Reduction? Smoking is addictive and causes a number of serious diseases Worldwide, it is estimated that more than 1 billion people will continue to smoke in the foreseeable future * Offering smoke-free alternatives to adult smokers is a sensible, complementary addition to existing tobacco control strategies Successful harm reduction requires that current adult smokers be offered a range of Reduced-Risk Products they can fully switched to, should they decide not to quit. * http://www.who.int/tobacco/publications/surveillance/reportontrendstobaccosmoking/en/index4.html Figure adapted from Clive Bates presentation to E-Cigarette Summit (19 Nov 2013) Note: Reduced Risk Products ("RRPs") is the term PMI uses to refer to products that present, are likely to present, or have the potential to present less risk of harm to smokers who switched to these products versus continued smoking. 5
Excess Risk of Smoking-Related Disease Disease-Specific Relative Risk [1] (by age) Relative risk of IHD, Stroke, COPD, and LC for an adult cigarette smoker
Excess Risk (%) % Excess Risk Excess Risk of Smoking-Related Disease Reduction in Excess Risk by Time Reduction of Quit in Excess Risk Over Time 100 80 Lung Cancer IHD COPD Stroke 60 40 20 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Time Since of Quit Quit (years) (years)
Our contact details Combustion
Elimination of Combustion Is Key Eliminating Combustion is Key Scientific studies have shown that as the temperature of tobacco increases, the levels of harmful chemicals formed increases Torrefaction Source: Baker R. R., 1975, Temperature variation within a cigarette combustion coal during the smoking cycle, High Temp. Sci., 7, 236-247. Coloration by PMI. Source: McGrath, T.E., Wooten, J.B., Chan W.G. and Hajaligol, M.R., 2007, Formation of polycyclic Aromatic Hydrocarbons from Tobacco: the Link between Low Temperature Residual Solid and PAH Formation, Food and Chemical Toxicology, 45,6,1039-1050
Our contact details The Tobacco Heating System 2.2
PMI s Reduced-Risk Product Portfolio Heated Tobacco Products Products Without Tobacco Note: The RRPs depicted are subject to ongoing development; therefore, the descriptions are illustrative and do not necessarily represent the latest stages of product development.
Why Heat Tobacco Rather than Burn It? The Tobacco Heating System (THS) (currently commercialized as IQOS in > 38 countries) is designed and has been demonstrated to: Heat tobacco without combustion Preserve elements of the taste, sensory experience, nicotine delivery profile, and ritual characteristics of cigarettes
Our contact details Scientific Assessment Approach
Disease Risk PMI s Scientific Assessment Approach From Epidemiology Assessment Framework Point of Intervention Post-Market Studies and Surveillance Consumer Perception and Behavior Assessment Clinical Trials Systems Toxicology Assessment Standard Toxicology Assessment Aerosol Chemistry and Physics Time Product Design and Control Principles Source: Smith, M.R., et al., Evaluation of the Tobacco Heating System 2.2. Part 1: Description of the system and the scientific assessment program. Regulatory Toxicology and Pharmacology (2016). http://dx.doi.org/10.1016/j.yrtph.2016.07.006 14
Assessment Framework: Informed by Epidemiology High-Level Adverse Outcomes Pathway of Cigarette Smoking Toxic Emissions Exposure Molecular Changes Disruption of Biological Mechanism Cell / Tissue Changes Disease Population Harm Analytical Chemistry Biological Networks Toxicology, Systems Biology, and Clinical Studies Models and Clinical Public Health HPHCs* Biomarkers of exposure *Harmful and potentially harmful constituents Proteomics Transcriptomics Genomics Lipidomics Oxidative stress Inflammation Cell adhesion and migration Cytology Cell death Cell proliferation Cell count Gross pathology Histopathology Lipid profile Atherosclerotic plaque formation Lung function
Our contact details Exposure Reduction and Carbon-Based Nanoparticles
% of Reference Cigarette Reduced Formation of HPHCs by Disease Categories 100% Reference Cigarette 50% 97% 93% 92% 92% 94% THS 2.2 produces an aerosol that contains on average 90-95% lower levels of harmful and potentially harmful chemicals than a reference cigarette 0% No. of toxicants Carcinogens in IARC Group 1 12 Carcinogens (FDA) Cardiovascular toxicants (FDA) Respiratory Toxicants (FDA) Reproductive and Developmental Toxicants (FDA) 29 8 18 7 Note: Intense Health Canada s Smoking Regime; Comparison on a per-stick basis; Excludes Nicotine
NNK (ng/stick) Total NNAL (pg/mg creat) [95% CI] T o t a l N N A L ( p g / m g c r e a t 9 5 % C I ) Carbon monoxide (mg/stick) COHb (%) [95% CI] COHb (%) Changes in Exposure to HPHCsin Healthy Human Subjects Reduced Exposure in Healthy Human Subjects Levels of HPHCs are Drastically Reduced in THS Aerosol Exposure is Significantly Reduced After Switching to THS 35 30 25 20 15 10 5 0 300 250 33.3 282-98.6%* 0.48 Leads to Cigarette THS Smoking Abstinence 8 7 6 5 4 3 2 1 0 0 1 2 3 204 5 Time 40 (days) 30 60 80 60 90 Time (Days) (days) 2 5 0 2 0 0 Carbon CO COHb Monoxide (%) NNK i S C 200 1 5 0 150 100-98.0%* Leads to 1 0 0 5 0 50 0 5.52 0 0 1 2 3 4 5 6 3 0 6 0 9 0 * On equivalent nicotine basis T i m e ( D a y s )
Percent of Cigarette Exposure [95% CI] P e r c e n t o f C i g a r e t t e E x p o s u r e Percent of Cigarette Exposure [95% CI] P e r c e n t o f C i g a r e t t e E x p o s u r e Reduced Exposure Similar to Smoking Abstinence Reduced Exposure in Healthy Human Subjects 1 0 0 THS Smoking Abstinence Cigarettes 8 0 6 0 4 0 2 0 0 o - t o l 1 - O H P 3 - H P M A T o t a l H E M A H M P M A C O H b B [ a ] P 4 - A B P C E M A N N N 2 - N A S - P M A M H B M A 1 - N A 1 0 0 8 0 N N A L Switching to THS achieves almost 95% of the reduction achieved by smoking abstinence Cigarettes 6 0 4 0 2 0 0 o - t o l 1 - O H P 3 - H P M A T o t a l H E M A H M P M A C O H b B [ a ] P 4 - A B P C E M A N N N 2 - N A S - P M A M H B M A 1 - N A N N A L
Reduced Formation of HPHCs by Disease Categories Cigarette smoke Carbon-based nanoparticles Median diameter = 75 nm Amount: 6x10 11 particles ~= 0.7 mg* Blank (Air) THS aerosol No solid particles Scanning Electron Microscopy images of the collected smoke/aerosol after passing through a thermodenuder set at 300º C to remove the volatile portion / collected material characterized by Electron Diffusive X-ray. * Under the Health Canada s Intense Smoking Regime. Pratte et al. Investigation of solid particles in the mainstream aerosol of the Tobacco Heating System THS2.2 and mainstream smoke of a 3R4F reference cigarette. Hum. Exp. Toxicol, 2017; 36:1115-1120 Cohen et al. Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015. Lancet 2017; 1907-1918.
Global Disease Risk Associated with PM 2.5 Cohen et al. Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015. Lancet 2017; 1907-1918. SD-654
Our contact details In Vitro Models of Disease
From Risk Assessment Framework to In Vitro Study Design In vitro model: Adhesion of monocytic cells to human coronary arterial endothelial cells 1. Cell exposure to 3R4F or THS 2.2 (aqueous smoke / aerosol extract) 2. Treatment of human coronary arterial endothelial cells (HCAEC) 3. Adhesion Assay Untreated MM6 cells and 4h-treated HCAECs were nuclearstained for 15 min. and then incubated together for 45 min After cell fixing and washing, remaining adherent MM6 cells and HCAECs were counted The adhesion rate was calculated Poussin et al. Systems toxicology-based assessment of the candidate modified risk tobacco product THS2.2 for the adhesion of monocytic cells to human coronary arterial endothelial cells. Toxicology 2016; 73 86.
From Risk Assessment Framework to In Vitro Study Design In vitro model: Adhesion of monocytic cells to human coronary arterial endothelial cells Poussin et al. Systems toxicology-based assessment of the candidate modified risk tobacco product THS2.2 for the adhesion of monocytic cells to human coronary arterial endothelial cells. Toxicology 2016; 73 86.
From Risk Assessment Framework to In Vitro Study Design In vitro model: Adhesion of monocytic cells to human coronary arterial endothelial cells Conclusions: 3R4F aqueous cigarette smoke extract promoted adhesion of MM6 cells to HCAEC in indirect and fresh direct exposure conditions At the same concentrations, no significant adhesion of MM6 cells to HCAECs The concentrations of THS 2.2 required to be increased by ~10 and 20 times to observe similar effects at functional and molecular levels to the ones observed with 3R4F Poussin et al. Systems toxicology-based assessment of the candidate modified risk tobacco product THS2.2 for the adhesion of monocytic cells to human coronary arterial endothelial cells. Toxicology 2016; 73 86.
Our contact details Animal Models of Disease
Disease Risk From Risk Assessment Framework to in vivo Study Design Animal Model: ApoE -/- mouse Concomitant analysis of CVD and COPD endpoints 8 months duration (approximately 40% of lifetime) Concomitant analysis of CVD and COPD endpoints Comprehensive analysis of molecular changes and mechanistic impact Exposure dose corresponds to ~30 cigarettes per day in human comparison Assessment Framework Group Exposure From Epidemiology Point of Intervention Cigarette Cessation 3R4F 3R4F Cessation Air Switching 3R4F THS Candidate MRTP THS Note: The descriptions in the chart are for illustrative purposes only Time Reference: Air Start Air Month 2 Month 8 Phillips et al. (2015) An 8-Month Systems Toxicology Inhalation/Cessation Study in Apo e-/- Mice to Investigate Cardiovascular and Respiratory Exposure Effects of a Candidate Modified Risk Tobacco Product, THS 2.2, Compared with Conventional Cigarettes. Toxicological Sciences, in press
Mechanism Disruption (% ± SEM) 0 20 40 60 80 100 Mechanism Disruption (% ± SEM) 0 20 40 60 80 100 Mechanism Disruption (% ± SEM) 0 20 40 60 80 100 Mechanism Disruption (% ± SEM) 0 20 40 60 80 100 Reduced Effects on Disease Mechanisms Cell Stress Cell Fate & Apoptosis Cell Proliferation Tissue Repair & Angiogenesis 1 2 3 6 8 3 6 8 3 6 8 1 2 3 6 8 1 2 3 6 8 3 6 8 3 6 8 1 2 3 6 8 Cigarette THS Switch Cessation THS Cigarette THS Switch Cessation THS
NPA 8-month Apoe-/- mouse switching study Interaction between monocytes and endothelial cells Network Perturbation Amplitude of: Inflammation/Endothelial cell activation Inflammation/Neutrophil Signaling Vascular Inflammation/ Endothelial cell monocyte interaction Cigarette THS Cessation THS Switch
Heart (left ventricle) Transcriptomics downregulated upregulated 3R4F vs. sham THS vs. sham Cessation vs. sham THS Switch vs. sham Muscle structure and function Inflammatory response Cardiovascular disease Szostak, J., et al. (2017). "Aerosol from Tobacco Heating System 2.2 has reduced impact on mouse heart gene expression compared with cigarette smoke." Food and Chemical Toxicology 101: 157-167.
From Risk Assessment Framework to in vivo Study Design Phillips, B., et al. (2015). "An 8-month systems toxicology inhalation/cessation study in Apoe / mice to investigate cardiovascular and respiratory exposure effects of a candidate modified risk tobacco product, THS 2.2, compared with conventional cigarettes." Toxicological Sciences 149(2): 411-432.
Atherosclerotic Plaque in the Aortic Arch Data from µct at month 7 Phillips, B., et al. (2015). "An 8-month systems toxicology inhalation/cessation study in Apoe / mice to investigate cardiovascular and respiratory exposure effects of a candidate modified risk tobacco product, THS 2.2, compared with conventional cigarettes." Toxicological Sciences 149(2): 411-432.
Mean ± SEM Mean ± SEM Mean ± SEM Atherosclerotic Plaque in the Aortic Arch Data from µct at month 7 Disease Endpoint for CVD Atherosclerotic Plaque in the Aortic Arch Data from µct at month 7 Plaque surface area (mm 2 ) Aorta mean occlusion (%) Plaque volume (mm 3 ) 30 10 2 20 10 5 1 0 0 0 Fresh Air Cigarette smoke THS Switch Cessation THS Phillips, B., et al. (2015). "An 8-month systems toxicology inhalation/cessation study in Apoe / mice to investigate cardiovascular and respiratory exposure effects of a candidate modified risk tobacco product, THS 2.2, compared with conventional cigarettes." Toxicological Sciences 149(2): 411-432.
Our contact details Exposure Response Study
Clinical Assessment Results to Date High-Level Adverse Outcomes Pathway of Cigarette Smoking Toxic Emissions Exposure Molecular Changes Disruption of Biological Mechanism Cell / Tissue Changes Disease Population Harm Analytical Chemistry Biological Networks Toxicology, Systems Biology, and Clinical Studies Models and Clinical Public Health Reduced Emissions Reduced Exposure Reduced Adverse Health Effects PK / PD Studies 4 single-use studies Reduced Exposure Studies 4 up to 3-month studies Exposure Response Study 6 + 6-month study Nicotine absorption similar to CC 15 biomarkers of exposure significantly reduced vs. CC Directional shift of CREs shift towards cessation *Harmful and potentially harmful constituents Statistically significant changes in CREs linked to smoking-related disease All co-primary CREs shifting in the same direction as they would upon smoking cessation
Primary Objective and Co-Primary Endpoints Smoking Cessation Epidemiologic link to smoking-related disease? Affected by smoking status Reversible upon smoking cessation Co-Primary Endpoints Representative of Patho-Mechanims Lipid Metabolism HDL - C Clotting 11 DTBX - 2 Endothelial function S ICAM - 1 CO acute effect Inflammation Oxidative stress COHb WBC PGF2 - a Assess the changes across a set of the 8 co-primary clinical risk endpoints in smokers who switch from smoking cigarettes to using THS as compared to those continuing to smoke cigarettes for 6 months Lung Function Genotoxicity FEV1 Total NNAL
Study Population Main Eligibility Criteria Healthy subjects. Minimum 30 year of age. 10 years of smoking history with at least 10 CC/day for the last year Subjects did not intent to quit smoking Clinically relevant disorders that would jeopardize the participants safety Female, not pregnant or breast feeding Subjects did use medication with an impact on co-primary endpoints Green Frame: Inclusion Criteria Red Frame: Exclusion Criteria
Run-in period Randomization Study Design and Disposition Exposure Response Study ZRHR-ERS-09-US (Clinical trials.gov: NCT02396381) ZRHR-ERS-09-EXT (Clinical trials.gov: NCT02649556) Adult healthy smokers not willing to quit 15 sites in U.S. Baseline visit 3-month visit 6-month visit 12-month visit
Statistical Analysis Success Criteria: To establish that the risk profile of THS is modified compared to cigarettes 1 All co-primary endpoints shift in the direction of cessation Primary Analysis: Predominant users of THS > 70% Establish Modification of Risk Smokers Health Profile Study-wise =0.05 Test-wise =0.031 2 3 5 out of 8 clinical risk endpoints are statistically significant (Hailperin-Rüger Approach) Majority of the smoking cessation effect is preserved If Modification of Risk is Established 5/8 significant clinical risk endpoints* Results of the study can be verified with the effects measured for smoking cessation *By using a 1-sided test with the Hailperin-Rüger adjusted α level for multiple testing (1.5625%).
Analysis Populations Reduced Exposure Studies vs Exposure Response Study Primary Analysis Population Primary Assessment Objective 3 months Reduced Exposure Study Use of no more than 2 CC in a single day during the 30 days preceding the visit Average product use within a 3-month period of not more than 0.5 CC/day Analysis of the effect of THS after full switching 6 months Exposure Response Study Analysis population: THS 2.2 as it is actually used 70% THS use over the 6-month analysis period 70% THS use on >50% of days in the 6- month analysis period Analysis of the effect of THS as actually used (up to 30% use of cigarettes)
Main Analysis Population THS-Use Randomized Product Use 70% THS use* Distribution of Randomized Subjects by Product Use Categories CC Arm (%) 95.9% 4.1% CC-Use Randomized Product Use 1% THS use* THS 2.2 Arm (%) 59.2 5.8% 0% 20% 40% 60% 80% 100% THS Use Dual Use CC Use Other use * Calculated over the study and on at least 50% of the Study Days
Product Use Time Period Product THS Use Mean / Day (Min, Max) CC Use Mean / Day (Min, Max) Baseline Cigarettes 18.5 (10.0, 65.0) 19.5 (10.0, 90.0) Postrandomization THS 16.5 (3.2, 63.0) < 0.01 (0.0, 0.44) Cigarettes 1.95 (0.0, 14.0) 16.8 (3.0, 43.7) Overall tobacco 18.5 (3.2, 63.5) 16.9 (3.1, 43.7)
NEQ (mg/g creat) ±95% CI Reduction in Exposure and Exposure to Nicotine -32.2% COHb -43.5% Total NNAL -16.2% Total 1-OHP 14 12 THS-use CC-use -28.4% 3-HMPMA 10-27.3% 3-OH-B[a]P 8-48.6% -40.8% CEMA Total NNN 6 4 2 10.1 9.2 9.89 8.85 8.63 9.29-25.0% -42.9% 3-HPMA MHBMA 0 Baseline Month 3 Month 6-70.0-60.0-50.0-40.0-30.0-20.0-10.0 0.0
Clinical Changes After 90 Days Reduced Exposure in Healthy Human Subjects Disease Pathway Endpoint Abstinence Effect at 3m [95% CI] Switching to THS Effect at 3m [95%CI] Lipid Metabolism HDL-C 0.0 mg/dl [-5.77; 5.84] 1.4 mg/dl [-2.3;5.0] Inflammation WBC -0.94 10 9 /L [-2.00; 0.13] 0.17 10 9 /L [-0.47; 0.81] Airway Impairment FEV1 2.0 % pred [-3.37; 7.36] 0.53 % pred [-2.79; 3.85] Endothelial Dysfunction sicam-1-9.9 % [-19.7;1.1] -10.6 % [-16.7; -4.0] Oxidative Stress 8-epi-PGF2α -8.5 % [-25.13; 11.8] -13.5 % [-23.6;-1.95] Clotting 11-DTX-B2-7.2 % [-37.7; 38.3] -3.6 % [-24.6; 23.3] Disease Pathway Endpoint Abstinence Effect at 3m [95% CI] Switching to THS Effect at 3m [95% CI] Lipid Metabolism HDL-C 6.4 mg/dl [2.5; 10.3] 4.5 mg/dl [1.17, 7.88] Inflammation WBC -0.41 10 9 /L [-0.95; 0.14] -0.57 10 9 /L [-1.04, -0.10] Airway Impairment FEV 1 1.94 % pred [-0.44; 4.31] 1.91 % pred [-0.14, 3.97] Endothelial Dysfunction sicam-1-10.9 % [-17.8; -3.4] -8.7 % [-14.94;-2.05] Oxidative Stress 8-epi-PGF 2α -5.9 % [-17.1; 6.8] -12.7 % [-21.81;-2.55] Clotting 11-DTX-B 2-19.4 % [-30.1; -7.0] -8.98 % [-19.52, 2.94] -
Changes in Clinical Risk Endpoints Endpoint Change From CC-use Observed Change LS Mean Difference / Relative Reduction Halparin Ruger Adjusted CI 1-sided p-value (0.0156) THS directional change vs SA (literature) HDL-C Difference 3.09 mg/dl 1.10, 5.09 <0.001* significant WBC Count Difference -0.420 GI/L -0.717, -0.123 0.001* significant sicam-1 % Reduction 2.86 % -0.426, 6.04 0.030 11-DTX-B2 % Reduction 4.74 % -7.50, 15.6 0.193 8-epi-PGF2α % Reduction 6.80 % -0.216, 13.3 0.018 COHb % Reduction 32.2 % 24.5, 39.0 <0.001* significant FEV1 %pred Difference 1.28 %pred 0.145, 2.42 0.008* significant Total NNAL % Reduction 43.5 % 33.7, 51.9 <0.001* significant * denotes significant p value at the 1.5625% level, following test multiplicity adjustment using the Hailperin-Rüger approach All CRE shifted in the same direction as smoking cessation effect observed in the literature 5 out of 8 clinical risk endpoints were statistically significant compared to continued smoking
Changes in Clinical Risk Endpoints When Adjusted for CEMA Exposure Levels Note: The predominant THS Use category group was stratified by CEMA quartiles 1 (bottom) to 4 (top). Note: Higher CEMA levels are indicative of higher levels of cigarette smoking. The panel for sicam-1 shows the THS vs. continued smoking LS means ratios. The panel for leukocytes (WBC) shows the THS minus cigarette smoking LS means differences.
Conclusion of the Exposure Response Study All clinical risk endpoints shifted in the same direction as the smoking cessation effect described in the literature 5 out of 8 endpoints showed statistically significant and favorable changes after switching to THS..despite the fact that up to 30% CC use was allowed in the primary analysis population Full switching is the best option for current adult smokers continuing to use tobacco products
COHb (%) [95% CI] Phillips B, Veljkovic E, Boue S, Schlage WK, Vuillaume G, Martin F, et al. An 8-Month Systems Toxicology Inhalation/Cessation Study in Apoe-/- Mice to Investigate Cardiovascular and Respiratory Exposure Effects of a Candidate Modified Risk Tobacco Product, THS 2.2, Compared With Conventional Cigarettes. Toxicological sciences : an official journal of the Society of Toxicology. 2016 Feb;149(2):411-32. Summary Cardiovascular In Vivo Endpoints Micro CT Exposure Reduction Clinical Risk Endpoints THS 2.2 8 Carbon Monoxide HDL-C WBC count 6 4 Cardiovascular Diseases sicam-1 11-DTX-B2 2 8-epi-PGF 2α 0 0 1 2 3 4 5 30 60 90 Time (days) Respiratory Disease COHb FEV 1 %pred Cancer Total NNAL
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